Behavioral Laboratory Customer Surveys and Support

ATTACHMENT B: Participant Screener

WISS Behavior Laboratory Participant Screener

E-mail: The IRS would like your help to get information [INSERT]. Please complete the following questionnaire and choose only one response per question.

Phone: The IRS would like your help to get information about [INSERT]. We would like to ask you a few questions about yourself to determine your eligibility for this study.

NOTE TO RECRUITERS: Participants must be at least 18 years old, filed a return in 20xx, and be able to complete the screener in English.

1. What category best describes your current age?

☐Under 18 (TERMINATE)

☐18 to 24 years ☐45 to 54 years ☐75 or older

☐25 to 34 years ☐55 to 64 years

☐35 to 44 years ☐65 to 74 years

2. Did you or your spouse file a Federal Income Tax Return in 2014 for income earned in 2013?

☐ Yes, I or my spouse filed a federal tax return

☐ No, neither I nor my spouse filed a federal tax return (TERMINATE)

☐ Not sure/Refused (TERMINATE)

3. Are you of Hispanic or Latino origin (ethnicity)?

☐Yes

☐No

3a. What is your race? (Please select one or more) [ACCEPT ALL MULTIPLE ANSWERS]

☐White

☐Black or African American

☐Asian

☐Native Hawaiian or other Pacific Islander

☐American Indian or Alaskan Native

4. What is the highest level of education you have completed?

☐Less than 9^th grade ☐Some college, no degree

☐9^th grade to 12^th grade, no diploma ☐Associate’s Degree

☐High school diploma or GED ☐Bachelor’s Degree

☐Some technical or vocational school ☐Master’s Degree

☐Technical or vocational school graduate ☐Post-Master’s Degree

5. What category best describes your total household income for the past 12 months?

☐$15,000 or less ☐$50,001 to $75,000

☐$15,001 to $25,000 ☐$75,001 to $100,000

☐$25,001 to $35,000 ☐$100,001 or more

☐$35,001 to $50,000

6. What is the primary language spoken at home?

☐English ☐Chinese

☐Spanish ☐Vietnamese

☐Russian ☐Korean

☐Other (please specify):_________

7. What is your marital status?

☐Single, never married ☐Separated

☐Married ☐Divorced

☐Civil union/domestic partnership ☐Widowed

8. Which of the following is the filing status you used on your 2014 tax return?

☐Single ☐Married Filing Separately

☐Married Filing Jointly ☐Qualifying Widow(er) with Dependent Child

☐Head of Household (single with dependent parent or child)

☐Don’t Know

9. What is your employment status?

☐Full-time Employee ☐Retired

☐Part-time Employee ☐Out of Work and Looking for Work

☐Student ☐Out of Work and not Looking for Work

☐Military ☐Unable to Work

10. Who did most of the work preparing your most recent tax return?

☐I myself (with software)

☐I myself (without software)

☐A paid preparer

☐An unpaid preparer (friend, relative, colleague or a volunteer preparer from a community organization)

11. For this most recent tax return, was your return sent to the IRS by paper via regular mail or electronically?

☐Regular mail

☐Electronically (e-File or Free File)

☐Other method (e.g. dropped off in person, etc.)

12. Do you own or use any of the following devices to access the Internet?

Yes No

Smartphone or other mobile device ☐ ☐

Tablet ☐ ☐

Laptop, desktop, or computer ☐ ☐

13. What familiar are you with <insert notice/form/etc.>?

☐Not at all familiar

☐Slightly familiar

☐Somewhat familiar

☐Moderately familiar

☐Extremely familiar

14. <Insert any additional project specific questions>